156C Hamakua Drive Kailua, Hawaii 96734

(808) 262-4538 Fax (808) 261-8525 www.kamaainakids.com

Dear Parents and Guardians, Pre-registration for the 2018-2019 SY will be available for current A+ students from May 1, 2018 through May 31, 2018. Any registration submitted after May 31, 2018 could result in your child being wait-listed for August 2018. The pre-registration procedures for the Kama`aina Kids A+ Program are outlined below. Please remember that your child’s registration is not final until the A+ Site Coordinator has reviewed your packet and issued a confirmation notice. STEP 1: Please complete ALL of the information requested on forms 1-4.

1. Kama`aina Kids Registration Form 2. DOE A+ Registration Form 3. Registration Agreement Form

A. Every item must be initialed by a parent/guardian. 4. Emergency Card

A. Please complete 1 card for each student.

Optional Forms 1. Automatic Tuition Payment Authorization Form

a. There is a one-time fee of $20 per family for each school year. This fee will be waived if Pre-registered and turned in by May 31, 2018

b. A new form must be completed each school year. 2. Application for Subsidized Monthly Fee (Located in the A+ Parent Handbook)

a. Please read the entire application before completing. b. In order for the application to be considered, the appropriate documents must

be attached. You will find the acceptable forms of documentation on the back of the Application for Subsidized Monthly Fee.

c. When processing the Application, proof of the most recent monthly income must be included. Therefore, at the start of the 2018-19 SY you will be asked to submit pay stubs for July 2018, even if pay stubs have already been submitted for earlier months.

d. If you submit a DHS Form 728 or Foster certificate, you do not need to include pay stubs

STEP 2: During pre-registration, please return your ch ild’s A+ Registration packet to the A+ Site Coordinator. Please do not return form s to the school adm inistration or classroom teacher. Completed forms should be re moved from the handbook and the rem aining portion should be kept for future reference. STEP 3: Upon receiving the completed registration packet, the A+ Site Coordinator must review each form to ensure that each section is filled out properly. This process may take a few days to complete. Once it is determined that all forms are complete, you will be issued a confirmation notice. Continued on back

Additional Notes:

During the 2018-2019 school year, monthly tuition for the A+ Program is $120.00 per child.

o There is no pro-ration of fees for days unattended. A+ starts on the first full day of school (Day 1 for grades 1-6).

o Kindergarten schedules vary at each school, A+ is available on their first full day. Payments are due by the first school day of the month. Please make checks payable to

Kama`aina Kids. NO CASH PAYMENTS WILL BE ACCEPTED AT THE SITE.

After May 31st Registration Forms may be turned in to the school administration office. They will only place your registration in the A+ box. The Site Coordinator will check the A+ box periodically throughout the summer and inform parents of eligibility and availability of space. Students on the wait list will be accepted in the order that their registration forms are received once staff have completed training and have a cleared criminal background check

At-Cost DHSA+ Start Date BC Start Date

A+ Group # CH1 CH2 CH3

Site Coordinator

PARENTS OR LEGAL GUARDIANS AUTHORIZED TO PICK UP CHILD:

Street

Street

MEDICAL INFORMATION:

I authorize only the following people to pick up my child or to be called in case of an emergency (in addition to parents/guardians):

FOR OFFICIAL USE ONLYBC Drop-In

Father / Legal Guardian Driver License #

DOB Room #

A+ REGISTRATION FORMCheck program(s) requested:

A+School Year

-

BC Monthly

Before Care (as needed)

Date

PARENT / GUARDIAN CONSENT FORM

PhoneAddress

Work Phone Home/Cell #

Name Relationship to Child Address Driver License # Work Phone Home/Cell #

CONFIDENTIALITY I understand that any information in this registration packet will not be disclosed to persons other than Kama‘aina Kids staff unless the parents or guardians of the child grant written permission for the disclosure or an emergency arises.

Parent/Guardian Signature

I hereby agree that, if Kama‘aina Kids staff is unable to contact me or one of the persons listed as emergency contact, I hereby consent that if my child exhibits signs of illness or injury, that at the discretion of the Kama‘aina Kids supervisor on duty, my child may be taken to the nearest medical facility and be given any examination/treatment that is deemed necessary by the personnel of the medical facility, and if permissible by medical facility, subsequently released to Kama‘aina Kids supervisor or staff-in-charge. I hereby give my child permission to attend and participate in the activities conducted by Kama‘aina Kids' A+, Before Care, and Holiday Care programs for the school year noted above. I hereby authorize Kama‘aina Kids to use my child’s name and video or photograph at any time and in any manner in connection with its advertising, publicity, and public relations programs. The video-photo may only be used by Kama‘aina Kids. No further claims will be made by me.

DISCIPLINE POLICY Discipline is used to assure the safety and well-being of all program participants. All children are expected to respect themselves, other people and their property. If a child is not following the guidelines of Kama‘aina Kids staff consistent with these expectations, then child will take a “time out” from the activity at the staff member’s discretion. A child with continued behavior problems will be sent to the Kama‘aina Kids’ Program Site Coordinator who may contact the parents for the purpose of removing the child from the program. Kama‘aina Kids reserves the right to refuse any child future participation in its programs. I hereby authorize Kama‘aina Kids to exercise these discipline policies in regard to my child.

Before Care (monthly)

Gender Grade (entering)

Child 1: Last Name First Name

Mother / Legal Guardian Driver License #

City Zip Code Home Phone

Gender DOB Grade (entering)

Room #Child 2: Last Name First Name

Gender DOB Grade (entering)

Room #

Email AddressKeep up-to-date on out of school programs and intersession day camps by signing up for our emails.

School Name

Please list medical conditions, allergies, medications, or special needs of child.

Date

Name Relationship to Child Address Driver License #

Doctor's Name

Medical Insurance & Policy Number

Employer

Employer

Mailing Address

Mailing AddressCity Zip Code Home Phone Cell Phone

Work Phone

Cell Phone

Work Phone

Child 3: Last Name First Name

2018-2019 Automatic Tuition Payments (ATP) Authorization Form We are excited to offer the safety, convenience, and ease of Tuition Express® – a payment processing system that allows secure, on-time tuition and fee payments

to be made from either your bank account or credit card.

 

Payments will be processed beginning with the first business day of each month. 

An email address is required to access receipts online at www.MyProcare.com. 

Credit union members: please contact your credit union to verify account and routing numbers for automatic payments.  

Payer Last Name  Payer First Name  Phone (required) 

     

Email Address:  Monthly Tuition (check program needed) 

  Child Last Name  Child First Name  Before Care  After Care  Total 1.      $65 $35* 

*Liholiho & Pearl Harbor Kai only (1-hour care) 

 $120 $ 

2.      $65 $35* *Liholiho & Pearl Harbor Kai only (1-hour care)  

 $120 $ 

3.      $65 $35* *Liholiho & Pearl Harbor Kai only (1-hour care) 

 $120 $ 

ATP Start Month  School Name Total Monthly Tuition  $    

Donation 

Kama’aina Kids is a not‐for‐profit organization.  Should you wish to make a tax‐deductible donation to assist our financial aid and scholarship program, please indicate your donation frequency and amount here: 

Donation Frequency: 

 One‐time  Monthly 

Donation Amount  

$ 

 

Section A (Credit Card) 

 Visa   Mastercard   American Express   Discover 

Cardholder Name  Credit Card Number  Exp Date  CVV 

       

Billing Address  City  State  Zip 

       

Section B (Bank Account) 

 Checking *Attach voided check (required)   Savings  

Name on Bank Account  Bank or Credit Union Name 

   

Routing Transit Number (see sample below)  Account Number (see sample below) 

   

Please note that in addition to the monthly tuition charge, the following fees shall be assessed: 

There shall be a $20 one‐time processing fee assessed per family for each school year. 

There shall be a $25 service charge assessed for any returned checks. 

I hereby authorize Kama’aina Kids to initiate credit card charges to the above‐referenced credit card account (Section A) OR, initiate debit entries to my checking or savings account, indicated above (Section B).  I am required to give 10 days written notice to cancel this authorization.  

Print Name  Authorized Signature  Date